Prediction of parturition in Holstein dairy cattle using electronic data loggers.

The objective of the present study was to assess the effect of parturition on behavioral activity [steps, standing time, lying time, lying bouts (LB), and duration of LB] 4 d before calving using electronic data loggers. Animals (n=132) from 3 herds were housed in similar freestall barns using a prepartum pen 21 d before the expected calving date and were moved into a contiguous individual maternity pen for parturition. Electronic data loggers were placed on a hind leg of prepartum heifers (heifers, n=33) and cows (cows, n=99) at 7±3 d before the expected calving date and removed at 14±3 d in milk. Calving ease (scale 1-4), parity, calving date and time, and stillbirth (born dead or died within 24h) were recorded. The number of steps (no./d), standing time (min/d), lying time (min/d), number of LB (no./d), and duration of LB (min/b) were recorded. Data were analyzed using MIXED procedures of SAS, adjusting for the herd effect. Only cows experiencing unassisted births (calving ease=1) were included in the study. An activity index was developed to predict calving time. Heifers and cows with unassisted births had significantly higher number of steps and longer standing time, decreased lying time, and more LB of shorter duration 24h before calving compared with d -4, -3, and -2. Additionally, the number of LB increased as both heifers and cows approached labor starting on d -2 and peaked at the day of calving. The time since the activity index increased over 50% to parturition did not differ between heifers and cows, and the activity index revealed the shift in activity on average 6h 14min (range from 2h to 14h 15min) before calf birth. This study provided evidence that heifers and cows approaching parturition showed a similar, but distinct, behavioral pattern that can be observed on average 6h before calf birth. The potential benefits of electronic data loggers as predictors of parturition along with proactive management practices should improve the overall survival and welfare of both the dam and calf.

Cost-identification analysis in oral cavity cancer management.

The objectives of this study were to investigate potential relationships between pretreatment patient-mix characteristics, treatment modalities, and costs generated during the pretreatment work-up, treatment, and 1-year follow-up periods for patients with oral cavity cancer (OCC). Another objective was to identify potential areas for cost reduction and improved resource allocation in the management of OCC patients. Using a retrospective cohort of 73 patients with OCC, pretreatment patient-mix characteristics and treatment modalities were evaluated in relation to university-based charges incurred during the pretreatment evaluation, treatment, and 1-year follow-up periods. Simple regression and stepwise multiple regression analyses were used to develop predictive models for cost based on independent variables, including age, AJCC TNM clinical stage, smoking history, American Society of Anesthesiologists (ASA) class, comorbidity as defined by the Kaplan-Feinstein grade and treatment modality. The dependent measurements included all physician, office, and hospital charges incurred at the University of Iowa Hospitals and Clinics during the pretreatment evaluation, treatment, and follow-up periods, as well as the total pretreatment through 1-year follow-up management costs. Independent variables that were identified as being significantly associated with treatment costs included T classification, N classification, TNM stage, unimodality versus multimodality treatment, and the Kaplan-Feinstein comorbidity grade. Age, smoking status, and ASA class were not significantly associated with costs. The majority of the OCC management costs were incurred during the treatment period. The most substantial decreases in management costs for OCC will be realized through measures that allow identification and treatment of disease at an early stage, in which single-modality treatment may effectively be used. Resource allocation for OCC should support the investigation of measures through which the diagnosis and treatment of OCC at the earliest possible stage is facilitated. The presence of comorbid illness is a significant component in the determination of management costs for OCC and should be included in analyses of resource allocation for OCC. The singular diagnosis of OCC encompasses a wide range of patient illness severity, and diagnosis-related reimbursement schemes for OCC treatment should optimally differentiate between early and advanced stage disease.

Drawing coagulation studies from arterial lines: an integrative literature review.

How much blood must be discarded from a heparinized arterial line to obtain accurate coagulation studies, specifically activated partial thromboplastin time? The published literature provides insight into the question and guidelines for practice in adult critical care. This article reviews and integrates findings from 14 research studies published from 1971 to 1993 on discarding blood from arterial lines for coagulation studies. Investigators compared activated partial thromboplastin time values from arterial and venous blood samples using various discard volumes, sites and sizes of catheters, and heparin flush concentrations. Similarities and differences in arterial and venous activated partial thromboplastin time were reported. Studies have demonstrated that adequate discard volume for activated partial thromboplastin time is 6 times the catheter dead space. These results should not be generalized to systemically heparinized patients, pediatric patients, or other types of heparinized lines such as pulmonary artery, central venous, or Hickman catheters.

Emotional responses of family members during a critical care hospitalization.

BACKGROUND: The needs and satisfaction levels of family members of critically ill patients have received much attention in the literature. The feelings of family members, however, have not been thoroughly investigated. To develop appropriate nursing interventions to assist family members in coping with a critical care hospitalization, accurate information about their emotional response to the situation is needed. OBJECTIVE: To examine emotional responses of family members and their descriptions of supportive behaviors of others during a critical care hospitalization. METHODS: An exploratory design was used to study 52 subjects with critically ill family members in the pediatric, neonatal, medical, surgical and cardiovascular intensive care units in a large tertiary care hospital. The subjects kept daily logs of their feelings and the supportive behaviors of others. Thematic analysis was used to identify major themes. RESULTS: Analysis revealed a broad range of powerful emotions throughout the intensive care unit stay. Negative and positive emotions such as despair and joy were sometimes identified by subjects within a 24-hour period. Although fear, worry, anger and exhaustion were dominant themes during the first 24 hours and when the family received bad news about the patient, there was no pattern of emotional response evident as the stay progressed. Some differences between subjects drawn from the medical and neonatal intensive care units were evident. CONCLUSIONS: The findings suggest that family members of critically ill patients experience deep emotional turmoil throughout the intensive care unit stay. Specific nursing interventions to promote adaptive coping are needed throughout the experience.

Reviews and summaries of research related to AACN 1980 research priorities: clinical topics.

This article reviews and summarizes the research conducted following publication of the 1980s American Association of Critical-Care Nurses' clinical research priorities. Original research conducted on the clinical priority topics between 1981 and 1991 was included. Review articles, doctoral dissertations, theses and abstracts were excluded unless judged to provide important information on the topic. Following the statement of each priority, progress in the area is summarized. Limitations and measurement issues are discussed as appropriate. Recommendations for future research are provided, and progress in the area is summarized.

Determining AACN's research priorities for the 90s.

The American Association of Critical-Care Nurses completed a three-phased process of priority identification for critical care nursing research. In phase 1, a 78-item survey was generated following a comprehensive review of potential research topics. In phase 2, approximately 1000 critical care nurses rated each item on the survey for importance to critical care nursing. Based on these results, the AACN Research Committee formulated a clinical and a nonclinical (contextual) list of research topics. Each list contained 25 topics. In phase 3, topics were given final rankings at a 1-day Consensus Conference on Research Priorities. Both Likert-type and magnitude estimation scaling were used to determine priority ranking of items on each list. As a result, both clinical and contextual research priorities were established for AACN.

Reviews and summaries of research related to AACN 1980 research priorities: contextual topics.

This article reviews and summarizes the research conducted following publication of the 1980s American Association of Critical-Care Nurses' contextual research priorities. Reports of original research conducted on the contextual priority topics between 1981 and 1991 were included. Review articles, doctoral dissertations, theses, and abstracts were excluded unless judged to provide important information on the topic. Following the statement of each priority, progress in the area is summarized. Limitations and measurement issues are discussed as appropriate. Recommendations for future research are provided, and progress in the area is summarized.

Impact of adult critical care hospitalization: perceptions of patients, spouses, children, and nurses.

This phenomenologic study describes the effects of adult hospitalization in a critical care setting on the family as perceived by patients, spouses, children in the family, and nurses. Tape-recorded interviews were completed with 12 spouses, 9 patients (2 mothers and 7 fathers), 11 children, and 12 nurses. Responses were analyzed by using systematic thematic content analysis. Themes that emerged with regard to how this event affected the family unit and individuals in the family included (1) lack of communication among family members; (2) protecting children from anxiety-provoking information; (3) overriding threat, exemplified by feelings of vulnerability, uncertainty, intense emotions, and physical illness in children; (4) disruption of normal home routines; (5) changes in relationships; and (6) role conflict. Nurses' perceptions of the impact of this event on parents, spouses, and children demonstrated some incongruences with perceptions of patients and family members. Practice implications from this study include the following nursing actions: (1) eliciting more comprehensive information about relationships among family members and the impact on the family; (2) developing mechanisms to promote communication among family members; (3) making referrals to community resources such as school nurses, counselors, and chaplains; and (4) teaching nurses and parents ways to help children cope with this event.

Effects of child visitation in adult critical care units: a pilot study.

OBJECTIVE: To examine the behavioral and emotional responses of the child and of the nonhospitalized adult family member (NHAFM) to facilitated child visitation in the critical care setting. DESIGN: Quasi-experimental, posttreatment design. SETTING: An adult surgical intensive care unit at a large Midwestern teaching hospital. PARTICIPANTS: Twenty families participated in the study, 10 families in a restricted and 10 families in a facilitated visitation group. Each family unit had a child, an NHAFM, and a critically ill family member. In the control group the NHAFMs visited the patient in the customary routine, but children were restricted from visiting. After a 2-week waiting period a facilitated child visitation intervention was implemented for the experimental group. OUTCOME MEASURES: The child completed measures on anxiety as measured by the Manifest Anxiety Scale and behavioral and emotional changes as measured by the Perceived Change Scale. The NHAFM completed measures on anxiety as measured by the State-Trait Anxiety Inventory and mood as measured by the Mood Adjective Check List. Family functioning, as measured by the Feetham Family Functioning Survey, and life event changes, as measured by the Life Event Scale, were examined as extraneous variables. INTERVENTION: The Child Visitation Intervention encompassed systematic facilitation and supervision of children visiting a critically ill adult family member in a surgical intensive care unit and provision of emotional support before, during, and after visitation (the intervention protocol may be obtained from the investigators on request). RESULTS: Children in the facilitated visitation group had a greater reduction (t = 4.0, df = 18, p = 0.0004) in negative behavioral and emotional changes as measured by the Child-Perceived Change Scale when compared with children in the restricted visitation group. CONCLUSION: Facilitated child visitation may help children deal with the critical illness of an adult family member and deserves further study.

Behavioral responses of family members during critical illness.

This articles describes the behavioral responses of adult family members to critical illness and how these responses change over the course of the hospitalization. A convenience sample of 52 family members of patients in intensive units completed the Iowa ICU Family Scale, a self-report tool measuring sleep, eating, activity, family role, and support behaviors. Scales were completed by family members each day during the first week and then weekly throughout the patient's ICU stay. Family members reported sleeping less with a poorer quality of sleep, less nutritional intake, an increased use of cigarettes, alcohol, and over-the-counter and prescription medications, and spending more time talking, visiting the patient, and waiting. Stress was highest at the time of the ICU admission, began to plateau at Day 6, and then dropped considerably by Day 28. These findings suggest that crisis intervention is important during the early phase of caring for critically ill patients and their family members.

Acute confusion/delirium protocol.

This abbreviated version of the Acute Confusion/Delirium Research-Based protocol provides clinical guidelines for the assessment and management of acute confusion/delirium in the elderly individual. A screening and ongoing surveillance program that is based on identified risk factors is recommended to prevent or minimize episodes of acute confusion in this age group. This protocol is part of a series of protocols developed to help clinicians use the best evidence available in the care of older adults.

Use of the nursing interventions classification by critical care nurses.

A survey of 111 critical care nurses was carried out to determine the frequency with which they perform each of the 336 interventions in the NIC. Forty-nine interventions were used at least daily, indicating a set of core interventions unique to critical care practice. These findings have implications for critical care practice, education, and research.

Nonpharmacologic treatment of pain.

Nonpharmacologic interventions for pain treatment are important complementary therapies but are not substitutes for pharmacologic management of pain. Use of nonpharmacologic pain treatments in critical care settings is helpful to decrease pain, but the challenge remains for nurses to have the knowledge, time, and skill to use these interventions in a busy daily practice with severely ill patients. Although numerous studies testing the effectiveness of nonpharmacologic interventions for pain management are available, the varying methods and interventions used in these studies make it difficult to draw conclusions. Further research on the use of these interventions for pain reduction is necessary to determine the most effective treatments and the conditions under which they should be used.

Translating research into practice. Considerations for critical care investigators.

Experimental multisite studies are needed to test adoption interventions that promote use of evidence-based guidelines in critical care practice. A research model (see Fig. 2) based on Rogers' diffusion of innovation model provides a conceptual guide for selecting interventions to test in translational research studies. Studies should address the four major areas of innovation adoption: (1) characteristics of the guideline, (2) users of the guideline, (3) methods of communicating the guideline, and (4) the social system in which it is being adopted. It is imperative that researchers study which interventions are most effective in promoting use of critical care evidence-based practices by nurses and physicians and how the social system of critical care environments affects adoption of such practices. Without this empiric knowledge, health care systems have little guidance in how to most effectively promote adoption of scientific evidence to improve care of critically ill patients.

Visiting critically ill adults: strategies for practice.

Visitation and proximity needs are consistently rated as very important by families of critically ill patients. This article reviews the literature on the proximity needs of families, presents nursing interventions to meet them, and suggests a plan for future research in this area.

Pain management in the culture of critical care.

Pain of critically ill patients is undertreated. Undertreatment of pain may be related, in part, to the culture of critical care practice, where nurses are challenged to meet competing patient demands. Implementation of appropriate pain management strategies is within the critical care nurse's scope of practice and must be a priority when delivering patient care. Although the multidisciplinary team can make the best holistic pain management plan, nurses have extensive independence and latitude in administration of pharmacologic and nonpharmacologic interventions. It is, in fact, "primarily the nurses' responsibility to administer the proper drug and dose at the proper time". Fostering a culture within critical care units that promotes optimal pain management is influenced by unit leadership, the values held by the staff, nurse competency, and an effective quality program that includes process and outcome indicators of pain management.

Developing family-focused care.

Critical care nurses have a responsibility to provide care from a family-systems perspective in which illness is not an isolated, time-limited event, but instead a highly stressful situation that evolves from the family's history and contributes dynamically toward its future. This article discusses nurse-family relationships, strategies to promote family-focused care, and mechanisms to make family-focused care a reality.

The Iowa Model of Evidence-Based Practice to Promote Quality Care.

The UIHC Department of Nursing is nationally known for its work on use of research to improve patient care. This reputation is attributable to staff members who continue to question "how can we improve practice?" or "what does the latest evidence tell us about this patient problem?" and to administrators who support, value, and reward EBP. The revisions made in the original Iowa Model are based on suggestions from staff at UIHC and other practitioners across the country who have implemented the model. We value their feedback and have set forth this revised model for evaluation and adoption by others.

Implementation of nursing diagnoses in nursing education.

Successful implementation of nursing diagnosis in nursing education begins with assessment of the program's philosophy, terminal objectives, faculty, and organizational framework. The outcome of successful implementation is a graduate that uses nursing diagnosis as the pivotal point in nursing practice. If nurses of today and tomorrow are to become competent diagnosticians in nursing, teaching diagnostic reasoning and nursing diagnosis formulation must be an integral part of the nursing educational process.

Interventions related to surveillance.

This study defined 10 nursing interventions that focus on purposeful acquisition, interpretation, and synthesis of patient data for clinical decision making. Critical and supporting activities used to carry out these interventions were delineated. Organizing and naming of monitoring activities are essential first steps to legitimizing, documenting, and investigating this area of professional nursing practice.